Breast Cancer

During
Pregnancy
Scientific session by Rizqy Tanza

Mentored by Dr. dr. Wirsma Arif Harahap SpB(K)Onk

Abstract
Breast cancer remains the most common cancer in women. In recent
decades, obstetricians are seeing an increasing number of women who
Breast become pregnant or desire to become pregnant after breast cancer
Cancer treatment because of a delay in childbearing for a variety of reasons,
Pregnancy including cultural, educational, and professional. Consequently,
breast cancer in young women often occurs before the
completion of reproductive plans.

A discussion among the patient, the oncologist, and the obstetrician on the
relative benefits of early delivery followed by treatment
versus commencement of therapy while continuing the
pregnancy is of utmost importance in order to reach a consensual
decision. The best available evidence suggests that pregnancy after breast
cancer increases the risk of recurrence. The birth outcome in women with a
history of breast cancer is no different from that in the normal female
population; however, increased risks of delivery complications have been
reported in the literature.
As concurrent pregnancy and breast cancer are uncommon, there are no
recommendations are
data from large randomized trials; hence,
mainly based on retrospective studies.
P regnancy B C
reast ancer Review
01 Risk of Breast Cancer

Diagnosis and
02 Presentation

03 Principles of Treatment

04 Multidiciplinary Approach
INTRODUCTION AND BACKGROUND
Scientific session : Pregnancy Breast Cancer
 Attributed to physiologic
Incidence 1:3.000 change and discounted
Average 3.5 cm not recognized on
2nd most common cancer in pregnancy
pregnancy

Insight diagnostic and therapy Memorial Sloan-Kettering

modalities cancer center:

Prognosis and best practice 44 of 56 did not diagnosed until

delivery (50% clinically symptom
on prenatally)
Outcomes….later stages and distant metastasis

Large tumor Metastases

Positive node

Vascular invasion
42% ER negative,
PR negative,
compared with 21%
in the age-matched
controls. Receptor
downregulation by
circulating estrogen
Risk of breast
cancer
Nulliparous
01 Multiparous

Early menarche
Late menopaused 02
 Diagnostic and
presentation
Place Your Picture Here Place Your Picture Here Place Your Picture Here

Painless mass Thickening Discharge from

82-95% Nipple
 Physical Examination

100%
ALL PREGNANT
Undergo breast evaluation +++
PRESENT OF LUMPS
Team of breast specialitis
Your Picture Here

Not advisable for the Calcification, asymmetric

investigation of breast density, axillary
cancer in pregnant women lymphadenopathy, and
skin and trabecular
thickening

Mammography
Your Picture Here

Ultrasonography is a The most common sonographic

sensitive (100% finding is an irregular mass
sensitivity in one series) lesion with posterior acoustic
enhancement

ultrasonography
Detecting axillary metastases
Responses to neoadjuvant Chemotheraphy

“Simple , sensitive modality for

initial evaluation..”
Your Picture Here

Considered safe during Exclusively indicated

pregnancy

Chest Radiography
Magnetic Resonance
Imaging

D
Does not use ionizing radiation

I Identify bone metastasis

A consensus in clinical practice, all staging

A investigations that are likely to cause any
risk to the fetus should be done only where
a positive result would alter immediate
management
Pathology

Core needle biopsy may be

an appropriate initial
procedure with a sensitivity of
90%. Biopsy as gold standard

Milk fistula formation, infection,

and bleeding
PRINCIPLES OF TREATMENT
Scientific session : Pregnancy Breast Cancer
 PRINCIPLES OF TREATMENT

Early delivery followed by Current stage of

EX
treatment versus disease(TNM), hormone

AM
TU
commencement of receptor status, and

EN

IN
trimester of pregnancy

AT
therapy

M
O

IO
M

N
ASCO Guideline: counsel
N
Pregnancy and future Fertility preservation.
IO

FU
AT
fertility Embryo and oocyte

TU
IC
PL

R
cryopreservation are both

E
M
O
standard fertility
C procedures
 SURGERY

First trimester
1st
• Mastectomy and axillary staging is
recommended in the 1st trimester
• BCS not preferred because need
Radiotheraphy
• Breast reconstruction not
recommended 2nd and 3rd trimester
• Surgery can be performed safely
without unexpected complications • Underwent mastectomy with
axillary clearance
• BCS with axillary dissection
• Isosulfan blue dye SNB not
2nd-3rd recommended
• In woman with advance
presentation , neoadjuvant
chemotherapy and surgery after
pospartum
 Maternal effect
Alteration in hepatic metabolism, renal clearance, protein
binding may effect drug clearance, amniotic fluid may
act as third space , increased toxicity like metotrexate.

Chemo-
Pre-Eclampsia and Myelosupression.
Fetal effect
All drugs have potential to across the

therapy plasenta. The effects gonadal

dysfunction, germ cell mutagenesis,
teratogenicity, impaired physical and
neurological problem
1st trimester
Chemotheraphy is avoided, significance
risk of spantaneus abortion and 17%
fetal risk malformation

2nd, 3rd trimester

Organogenesis was complete, Using CAF regimen: no
detectable malformation and death
 Chemotherapeutic agent

Safe during 2nd and 3rd , dose

<70 mg per cycle, If Exceed
Anthracyc Metotrex Contraindication because
with risk 30 fold. No risk factor
lines ate abortfacien and lead congenital
for fetal cardiotoxicity
defect

Remain unclear
Paclitacel combination with Taxanes 5FU Bony aplasia and hypoplasia
cisplatin >28 weeks, docitaxel
single or combination with
doxorubricin >14 weeks,
vinorelbine with 5FU at least 2nd
trimester

Congenital malformation from Cyclofos Trastuzu Asociated with Anhydramnions

alkylating agent ranging 4-13% famide mab
at late pregnancy
 Therapeutic agent

Anti emetic
Combination of dexamethason and ondansetron safe
01 during 2nd -3rd

40% 80% 60% 50%

Granulocyte coloni stimulating factor
Used safely on pregnant patients
02

Hormonal agent
Tamoxifen potentially teratogenic in animal studies. In
03 patient with metastatic disease with no damage.
Ambigous genitalia and cranifacial defect. Usually delay
until late pregnancy
Biposphonates
The use of pamidronate reported with malignancy
04 associated hypercalsemia
 Termination of Pregnancy

Consideration: depend on prognosis and treatment option

Elective abortion and castration did not

show improved on survival
Pregnancy….
After breast cancer
Certain
chemotherapeutic
drugs may affect a
woman’s fertility, but
During Breast
many women will still
cancer
be able to become
Despite the pregnant after
responsiveness of treatment. The
breast tissue to percentage of
Before breast
hormonal stimulation in patients who have
cancer
women who were the pregnant and full-term pregnancies
diagnosed as having lactation state (when after a breast cancer
breast cancer within controlled for patient diagnosis is
two years of giving age and disease minuscule.
birth was poorer than stage), the prognosis
that in other women does not seem to differ
with breast cancer from that in non-
pregnant patients of
the same age and
stage of disease
Pregnancy Breast Cancer
Monitoring of pregnancy
Before starting chemotherapy, fetal ultrasonography should be
performed to ensure that the fetus appears normal, and the
gestational age and expected date of delivery should be
estimated. Ultrasonography should be performed before every
cycle of chemotherapy to assess fetal growth. Any fetal
abnormalities and pregnancy-related complications should be
treated based on the standard recommendations.
Delivery and postpartum
It is recommended that the timing of delivery be approximately
three weeks after the last dose of chemotherapy. The placenta
should be sent for histopathological examination to rule out the
rare possibility of placental metastases.
Breastfeeding
Breastfeeding during chemotherapy and hormonal therapy is
contraindicated, as most drugs can be excreted in breast milk.

Future Pregnancy
It is recommended that pregnancy should be delayed for at least two
years after treatment completion. The recommendation for future
conception may be based on the prognosis of individual women.
Women with Stage IV disease should not consider pregnancy, and
women with Stage III disease should avoid becoming pregnant for at
least five years after treatment. Women with recurrent Stage I or II
tumors should not consider conception because of the intensity of the
required treatment and the poor prognosis.
 Thank You
Scientific session : Pregnancy Breast Cancer